SUB-86626
Priya Raman· +12095550182·LM-WC-3308714-26(WC-CA)
Promoted to claim — opening…
SUB-86626CLM-14707
Action Tracker
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Activity (1)
Convert submission to claim
All WC conversion basics are present (policy linked, DOI, workplace address, mechanism, cause); the specialist WC driver will handle three-point contact, wage basis, and compensability.
Claim Data
Everything captured about this loss. Amber values are live — extracted in-call before reconciliation. Confirm and override as needed.
Policy
- Policy #
- LM-WC-3308714-26
- Product
- WC-CA
- Risk address
- 1450 Almond Terrace Drive, Modesto, CA, 95358
Reporter
- Reporter name
- Marcus Ellison
- Reporter phone
- +12095550182
- Reporter email
- Priya.Raman@Valleverdefoods.Com
Policy
- Policy number
- required
Loss details
- Type of claim
- —
- Date of loss
- required
- Approximate time of loss
- —
- Loss address
- —
- What happened (caller narrative)
- —
- Areas affected
- —
- Damage description
- —
- Property occupied at time of loss
- —
- Accident location
- —
- Citation issued (statute)
- —
- Adverse carrier claim number
- —
- Authorities called
- —
- Mitigation started
- —
- Occupied at loss
- —
- People injured
- —
Next Steps
- Payment method
- —
- Has contractor estimate
- —
- Callback number confirmed
- —
- Preferred follow-up channel
- —
- Best time to reach them
- —
- Has evidence to share
- —
Authorities
- Authorities involved
- —
- Police report number
- —
- Police agency
- —
- Fire report number
- —
- Fire department
- —
Business Income
- Average daily rate (ADR)
- —
- Occupancy rate (%)
- —
- Period of restoration — start
- —
- Period of restoration — end
- —
- Extra expense incurred
- —
Cause Fire
- Fire origin
- —
- Fire extinguished by
- —
- Smoke damage in unaffected rooms
- —
Cause Theft
- Point of entry
- —
- Items stolen
- —
- Serial numbers (if shared)
- —
Cause Water
- Water source
- —
- Water shut-off accessible
- —
- Mold visible
- —
- Pipe location
- —
- Leak repaired
- —
- Water on the floor
- —
- Room > 400 sq ft
- —
- Room/floor finished
- —
Cause Wind
- Roof age (years)
- —
- Shingle / roof type
- —
- Interior leaks visible
- —
Commercial intake
- Caller's role at the organization
- Employee
- Named insured (organization)
- Valle Verde Foods, LLC
- Financial contact name (GM/owner)
- —
- Financial contact email
- —
- Rooms / units out of service
- —
Damages
- Alleged cost of repair
- —
- Implicated trades
- —
- Buildings / units affected
- —
Employee
- Date of birth
- —
- SSN (last 4)
- —
- Date of hire
- —
- Occupation
- —
- Employment status
- —
Employment & wages
- WC class code
- 8018
- Employer FEIN
- LM-WC-3308714-26
- Employer NAICS
- —
- Employee preferred contact channel
- —
- Employee represented by counsel?
- —
- Attorney of record
- —
- Modified duty status
- —
- Modified duty task list
- —
- Wage continuation during modified duty
- —
- Base hourly rate
- 26.50
- Scheduled hours per week
- 40
- Overtime hours (52 wk)
- —
- Actual gross earnings (52 wk)
- —
Estimate
- Repair facility
- —
- Repair facility phone
- —
- Estimate number
- —
- Estimate date
- —
- Estimator
- —
- Estimate type
- —
- Parts subtotal
- —
- Labor subtotal
- —
- Materials subtotal
- —
- Estimate total
- —
- Supplement total
- —
- Revised total
- —
Fleet Vehicle
- Fleet unit number
- —
- Vehicle
- —
- VIN
- —
- Odometer at loss
- —
- Drivable after loss
- —
Injury
- Injury mechanism
- Overexertion Lifting
- Date of injury (DOI)
- 2026-03-02
- Time of injury
- 2:10 P.M.
- Date reported to employer
- 2026-03-02
- Date reported to claims administrator
- 2026-03-03
- Jurisdiction
- CA
- Workplace address
- 1450 Almond Terrace Dr, Modesto, CA, Aisle D14, Dry Goods Warehouse
- Body part
- Arm/Shoulder
- Side (L/R/bilateral)
- Right
- Nature of injury
- Strain / Tear
- Mechanism narrative
- Employee Was Pulling A Case Down Off A Rack In The Dry Goods Warehouse When They Felt A Pop In The Right Arm/Shoulder.
- ICD-10 (primary)
- —
- ICD-10 (secondary)
- —
- Cause narrative
- Pulling A Heavy Case From An Elevated Shelf With Catching Mechanism.
- Written work restrictions
- —
- Restrictions effective date
- —
- Restrictions estimated duration (weeks)
- —
- Restrictions reassessment trigger
- —
Inspection report
- Inspection completed at
- —
- Inspection findings summary
- —
- Replacement cost value (RCV)
- —
- Actual cash value (ACV)
- —
- Recoverable depreciation
- —
- Net ACV payable now
- —
Liability
- Police report status
- —
- Disputed liability facts
- —
- Agent-filed FNOL
- —
Litigation
- Court
- —
- Case number
- —
- Date complaint filed
- —
- Date served
- —
- Responsive pleading due
- —
- Causes of action
- —
- Claimant
- —
- Plaintiff counsel
- —
- Civ. Code § 910 (SB800) notice — date served
- —
Mitigation
- Mitigation started
- —
- Mitigation vendor
- —
- Mitigation vendor phone
- —
- Contractor engaged
- —
- Contractor
- —
- Contractor phone
- —
- Preferred cleanup vendor
- —
Mitigation invoice
- Mitigation invoice vendor
- —
- Mitigation invoice total
- —
- Mitigation invoice date
- —
- Mitigation invoice number
- —
- Mitigation invoice balance due
- —
- Mitigation service start
- —
- Mitigation service completion
- —
Other
- Estimated amount
- —
- Best callback window
- —
People & witnesses
- Injuries reported
- —
- Injury summary
- —
- Witnesses
- Luis BarragáN, Order Selector
Program
- Client approval status
- —
- Client approved on
- —
Project
- Project name
- —
- Project address
- —
- Insured's role on the project
- —
- Property type
- —
- Number of units
- —
Property Condition
- Displaced from property
- —
- Where they're staying now
- —
- Displaced since
- —
- Water shut off
- —
- Power shut off
- —
- Gas shut off
- —
- Prior claims at this property
- —
- Rooms affected
- —
- Floors affected
- —
- Opening to the outside
- —
Provider
- MPN status
- —
- Specialty
- —
Rental
- Rental reservation
- —
- Rental daily rate
- —
- Rental days
- —
- Rental total
- —
- Rental return date
- —
Repair
- Repair shop
- —
- Estimate number
- —
- Original estimate total
- —
- Days to repair (DTR)
- —
- Projected completion date
- —
- Supplement 1 — delta
- —
- Revised repair total
- —
- Final invoice total
- —
- Repair completed
- —
- Drop-off scheduled
- —
- Drop-off reschedule requested
- —
Repairs
- Body shop chosen
- —
- Body shop name
- —
Risk transfer
- Trade
- —
- Subcontract requires additional insured status?
- —
- Indemnity clause type
- —
- COI deficiencies
- —
- COI policy period
- —
- COI certificate holder
- —
Statutory clocks
- MPN ID
- —
Coverage trigger
- Date of substantial completion
- —
- Notice of Completion — recorded date
- —
- Alleged manifestation date
- —
- Potentially triggered policy years
- —
- Other liability coverage in the trigger window
- —
Vehicle
- Vehicle year
- required
- Vehicle make
- required
- Vehicle model
- required
- Drivable status
- required
- VIN
- —
- License plate
- —
Communication Hub
Reach the insured, vendors, or other parties. Pick a contact and channel — phone, SMS, or email. Every reply is logged here automatically.
Priya Raman
+12095550182 · priya.raman@valleverdefoods.comPrefers email
New WC claim — Ellison, Marcus — DOI 3/2/26 — right shoulder
Good morning, Reporting a new injury from yesterday afternoon. One of our order selectors, Marcus Ellison, hurt his right shoulder pulling a case down off an overhead rack in the dry goods warehouse. His supervisor sent him over to Valley Occupational Health the same afternoon and they took an x-ray. He is back today on light duty. Attached are the 5020, the claim form he filled out, the supervisor's incident report with a witness statement, some photos our supervisor took of the rack and the case, and his job description. Please let me know the claim number and who is handling it. He is asking about whether his time yesterday afternoon gets paid and I want to give him a straight answer. Let me know if you need anything else from us. Thanks, Priya Raman HR & Safety Manager | Valle Verde Foods, LLC (209) 555-0182
Re: New WC claim — Ellison, Marcus — DOI 3/2/26 — right shoulder
Priya, Confirming receipt of the new injury report for Marcus Ellison. The claim is set up as CLM-14707 under policy LM-WC-3308714-26, and Sam Chen is the assigned adjuster. Up to $10,000 in medical treatment inside the Larkspur Mutual Medical Provider Network (MPN ID 2519) is authorized as of today under Labor Code §5402(c), pending the compensability determination. Marcus can continue treating with Valley Occupational Health, which is in the network. On your question about pay for the afternoon of the injury: California requires the employer to pay the injured worker in full for the day of injury, so no workers' comp wage-replacement benefit is owed for that afternoon — it goes through your payroll as a regular day. If he stays on modified duty at his full wage going forward, no wage-loss benefits are payable, since there is no wage loss to replace. If that ever changes (hours cut, taken off work by the doctor), we'll put him on temporary disability. We have the 5020, the DWC-1, the supervisor's incident report with Mr. Barragán's witness statement, the photo log, and the order-selector job description. We're reaching out to Marcus and to Valley Occupational Health today. I'll write to you again tomorrow morning to close out the employer portion of three-point contact — a few questions about wages and modified duty. Nothing needs preparing, though if you can have his payroll records to hand it will save us a second exchange. Sam Chen Larkspur Mutual — Claims
Documents
Files emailed in (or uploaded) on this submission, parsed and classified on arrival. Extracted fields link back to their source pages — click a field to see where it came from. High-confidence values feed the intake fields above.
02_DWC1_Claim_Form.pdf
dwc 1 · 4 pages
